MEDICARE: DAENA C. WILDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	KY-0136	KY
2	237600000X	Audiologist-Hearing Aid Fitter	0532	KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CB5773	OTHER	GA	RR MEDICARE GRP
2	K117240	OTHER	KY	MEDICARE PTAN
3	640004124	OTHER	GA	RR MEDICARE PIN

General Provider Information

NPI Number	:	1285739417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAENA C. WILDS

Provider Business Mailing Address
First Line	:	1036 AMBERLEY WAY
Second Line	:	STE. A
City	:	RICHMOND
State	:	KY
Zip	:	40475-8979
Country	:	US
Telephone Number	:	859-623-4458
Fax Number	:	859-623-4459

Provider Business Practice Location Address
First Line	:	1036 AMBERLEY WAY
Second Line	:	STE. A
City	:	RICHMOND
State	:	KY
Zip	:	40475-8979
Country	:	US
Telephone Number	:	859-623-4458
Fax Number	:	859-623-4459

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	03/30/2016

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Directions to “ DAENA C. WILDS ” Practice Location

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